Friday, December 08, 2006

A Social Science Argument for a Comprehensive Community-Based Approach to Diabetes Prevention – Juliane Scrivens

Diabetes affects millions of Americans. In 2005, 14.6 million people were diagnosed with diabetes in the United States (National Institute of Diabetes and Digestive and Kidney Diseases, 2005). Despite the plethora of prevention programs from health organizations such as the Centers for Disease Control and the National Institutes of Health, diabetes rates have risen significantly in the last ten to twenty years (Centers for Disease Control and Prevention, 2005). If these prevention programs were successful, the rate of diabetes diagnosis would be decreasing not increasing. There must be a significant component missing from these prevention programs that is causing them to be so unsuccessful. That missing component is a comprehensive community-based education plan. This new approach would expand on the current programs’ focus on how to prevent diabetes giving the public increased education on what the disease is and why it should be prevented.

Most diabetes prevention programs center on ways to prevent diabetes (National Diabetes Education Program, 2006). They continually discuss that being obese and having a sedentary lifestyle can lead to the development of diabetes. Most current prevention efforts explore how to avoid these two negative health outcomes by suggesting becoming more physically active and eating a healthier diet. While this is an important strategy to consider when attempting to decrease the number of new diabetes diagnoses, simply concentrating on how to combat diabetes is not enough. What these programs do not address is what diabetes is and the damage this disease can cause. In order for these programs to become more successful, it is essential that they include a different type of education in their interventions. This added element could provide communities most at-risk for diabetes with the knowledge of what this disease is and why it must be prevented. Increased knowledge of the disease and its consequences could lead to lower rates of diabetes diagnosis.

Using the Health Belief Model for diabetes prevention

Public Health practitioners often use the Health Belief Model, a psychological behavior model, to create behavioral interventions surrounding disease. An important component of this model is “perceived severity.” This part of the model deals with “one’s opinion of how serious a condition and its consequences are” (University of Twente, 2004). In order for the target of an intervention to be aware of this perceived severity, education of the disease’s consequences must be included. The individual must receive more information than how to prevent the disease so that he or she can develop this notion of perceived severity. The basic premise of this psychological model is outlined in Rosenstock’s article entitled “Historical origins of the health belief model.”
… in order for an individual to take action to avoid a disease he would need to believe (1) that he was personally susceptible to it, (2) that the occurrence of the disease would have at least moderate severity on some component of his life and (3) that taking a particular action would in fact be beneficial by reducing his susceptibility to the condition, or, if the disease occurred, by reducing its severity , and that it would not entail overcoming important psychological barriers such as cost, convenience, pain, embarrassment. (Rosenstock, 1964)
With diabetes prevention programs primarily discussing general health activities (exercise, a healthy diet, etc.) as a way to prevent diabetes, the idea of an individual’s need to understand the severity of the disease and its consequences is being entirely ignored. Simply informing an individual of what his or her options are for health behavior is not going far enough with the intervention. Individuals must be given the tools to determine what will happen if they are not completing these healthy behaviors in order for them to even consider the behavior itself. In addition to concentrating on ways to prevent diabetes, prevention programs could focus on consequences of diabetes such as loss of vision, nerve damage, and cardiovascular disease (LifeMed Media, Inc., 2006). All of these complications could cause an individual to see the disease as one that could severely hamper and/or shorten his or her life leading to an increased perception of severity. As it currently stands, most people view diabetes as an easily controllable or inevitable chronic disease. Education must be used to give individuals information that will impress upon them the consequences of unhealthy behavior that could lead to a diabetes diagnosis and why diabetes is such a serious disease.

Expanding the Health Belief Model to a community approach

It must be considered, however, that one constraint of the Health Belief Model is that it only focuses on the individual level. If the goal were to consider broadening the approach of diabetes prevention programs, it would be a mistake to then narrow the approach by only looking at the individual. Instituting educational interventions on a family and community level as well as on the individual level could increase the scope of the intervention. In an article entitled “Realistic outcomes: lessons from community-based research and demonstration programs for the prevention of cardiovascular disease,” Mittelmark et al discusses the way in which several community-based programs throughout the United State have used “the promotion of prevention as a community theme” to “favorably modify [the] health behaviors” of community members. Using strategies such as the involvement of places of worship, schools, and community leaders, proved that a community-wide prevention approach could be very successful (Mittlemark, et al, 1993). These same strategies could be used in diabetes prevention while still maintaining a focus on education. Diabetes interventions could draw on the idea of using the community as a vehicle for providing educational information about diabetes. It is likely that this community-based prevention approach for diabetes education could be used to help increase the healthy behaviors that would then result in a decrease in diabetes diagnoses.

A use of education in prevention: HIV/AIDS as an example

Education has been shown to be a crucial component in the prevention of other diseases. To create more effective diabetes prevention programs, public health practitioners could look to these other successful prevention programs. In the case of HIV/AIDS, education has been used to make the public knowledgeable about what the disease is and how it is contracted. Throughout recent years, education has helped lead to less risky sexual behavior and lower levels of HIV infection (Coombe, Kelly, 2001). At a time when a vaccine has not been found for this disease, it has been asserted that “education is the best protection against HIV infection” (Vandemoortele, Delamonica, 2000). However, HIV/AIDS programs emphasize not only strategies to prevent the disease, but they strongly stress the deadly results of not heeding their warnings.
The authors of diabetes prevention programs could use the example of the success of education in HIV/AIDS prevention to improve the results of their interventions. Just as HIV/AIDS prevention programs give information on how HIV is contracted, diabetes prevention programs could concentrate on how health behaviors such as obesity and a sedentary lifestyle contribute to the likelihood of the development of Type 2 diabetes. Just as HIV/AIDS prevention programs speak of the devastating effects of AIDS, diabetes prevention programs could call the public’s attention to how an increase level of glucose in the blood can severely damage many of the body’s organs leading to blindness, heart disease, and significant nerve damage (LifeMed Media, Inc., 2006). Prevention programs should include not only the knowledge of the potential causes of the disease, but its harmful results, which in turn would make them more successful.

Incorporating contextual factors for prevention in minority populations

A recent trend in diabetes prevention is to target racial groups that have been found to be at the highest risk for developing diabetes. This is an important step toward a more community-based approach to diabetes prevention. However, even with these interventions, minority groups such as African Americans and Hispanics have been shown to continue to have significantly higher rates of diabetes than Caucasian Americans (Hovert et al, 2006). What is missing from these targeted prevention programs again is education that emphasizes more than how to prevent the disease. Although the authors of these programs make their interventions more accessible to minority populations, they are still not explaining why their audience should change their health behavior to avoid developing diabetes.
Minority populations have been shown to be more resistant to prevention programs. Due to events such as the Tuskegee Syphilis Study, a mistrust of health professionals has persisted in many minority populations, but particularly in the African American population (Thomas, Quinn, 1991). It is essential when targeting these already resistant populations, that as much information as possible about a disease and its consequences is provided. In this case, not only is education important in order for the intervention target to comprehend the severity of the disease, but with this mistrust already present, additional educational information could provide for a more open dialog. This is particularly important considering that African Americans and Hispanics have been shown to be at a higher risk genetically for type 2 diabetes (Campos, 2006). Because these minority populations are more genetically predisposed to diabetes, they often develop a fatalistic view toward diabetes diagnosis. This is particularly true in the Hispanic community. In this population, it is commonly believed that diabetes “is the result of divine intervention” (Campos, 2006). This fatalistic view of health shows that it is vital to consider the particular views of a community when constructing intervention programs. By providing these minority communities with more information about diabetes and its consequences, public health practitioners would be more likely to reach a group of people who not only have a mistrust of health care providers, but also may believe that developing the disease is inevitable. Adding in a community-based approach to this educational information would also help to increase the perceived validity of the provided information by the prevention’s target audience. Deleivering the message in a safe environment like a place of worship or a school or hearing the information from a trusted community leader may overcome some of these obstacles. It would be particularly effective for community members to be the vehicles for educational information in this case because it would help to foster trust in the information that was being provided. This information, in addition to coming from a trusted source, would allow the intervention’s target population to gain knowledge of why they should be trying to prevent diabetes and that it is a disease this is possible to prevent.

Diabetes prevention programs have not been completely successful in the United States because they ignore the importance of the inclusion of community-based education in their interventions. As seen in psychological behavior models such as the Health Belief Model, it is necessary for the audience of a public health intervention to recognize the “perceived severity” of a disease in order to believe that it is imperative to follow the healthy behavior that a public health approach is trying to promote. It is with education that public health practitioners could increase knowledge of this perceived severity, and thus, make their interventions more compelling. This information must in part, however, be conveyed to the public through trusted community members and organizations to be successful. These groups would be able to help enlighten public health practitioners on the specific characteristics of a community that would help them to craft an intervention approach. Other disease interventions such as HIV/AIDS prevention have used education effectively to decrease the unhealthy behavior that leads to new infection. Diabetes prevention programs could use the example that HIV/AIDS provides to increase public awareness of the consequences of developing diabetes. It is with a community-based approach that diabetes prevention programs could develop the view that education is an essential piece in the puzzle of prevention and can lead to lower rates of diabetes diagnoses particularly in minority communities. It is with the inclusion of community-based education in diabetes prevention programs, that we can begin to lower the rates of new diabetes diagnoses in the United States. This is a skyrocketing disease that needs a new approach for the benefit of all Americans.

Campos, Carlos (2006). Narrowing the Cultural Divide in Diabetes Mellitus Care: A Focus on Improving Cultural Competency to Better Serve Hispanic/Latino Populations. Insulin, 1, 70-77. Retrieved December 3, 2006 from:
Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, (2005, October 6). CDC's diabetes program - Data & trends - Prevalence of diabetes - Number in millions of people. Retrieved November 11, 2006, from Centers for Disease Control and Prevention Web site:
Coombe, C, & Kelly, M (2001). Education as a Vehicle for Combating HIV/AIDS. Prospects, Retrieved November 11, 2006, from
Hovert, D. L., Heron, M. P., Murphy, S. L., & Kung, H. (2006). Deaths: Final Data for 2003. National vital statistics reports, 54, Retrieved November 11, 2006, from
LifeMed Media, Inc., (2006, September 8). Type 2 diabetes complications. Retrieved November 11, 2006, from LifeMed Media, Inc. Web site:
Mittelmark, M. B., Hunt, M. K., Heath, G. W., & Schmid, T. L. (1993). Realistic outcomes: lessons from community-based research and demonstration programs for the prevention of cardiovascular diseases. Journal of Public Health Policy, 13, 437-62.
National Diabetes Education Program, (2006). Small Steps, Big Rewards. Prevent type 2 diabetes. Retrieved November 11, 2006, from National Diabetes Education Program Web site:
National Institute of Diabetes and Digestive and Kidney Diseases, (2005, November). National Diabetes Statistics. Retrieved November 11, 2006, from National Diabetes Information Clearinghouse (NDIC) Web site:
Rosenstock, I. M. (1964).Historical origins of the health belief model. Health Eduacation Monographs. 2, 328-335.
Thomas, S. B. & Quinn, S. C. (1991). The Tuskegee Syphilis Study, 1932 to 1972: Implications for HIV Education and AIDS Risk Education Programs in the Black Community. American Journal of Public Health, 81, Retrieved November 11, 2006, from
University of Twente, The Netherlands (2004, September 6) Health Belief Model. Communication Theories. Retrieved November 11, 2006, from University of Twente, The Netherlands Web site:
Vandemoortele, J., & Delamonica, E. (2000). The "Educaiton Vaccine" Against HIV. Current Issues in Comparative Education (CICE), 3, Retrieved November 11, 2006, from


Blogger Michael Siegel said...

This is a very cogent example of a situation in which the use of the health belief model, albeit with more of an appreciation of social factors as well, could help to improve interventions, because diabetes is one of the few examples where the public really doesn't have a clue of how serious and gruesome the disease can be.

When you mention lung cancer to someone, or any type of cancer, there is little doubt as to the severity of what you are talking about. But with diabetes, it has almost become an assumed and accepted condition, rather than a deadly disease. Perhaps because the prevalence is so high, the perceived severity has fallen off the map.

In particular, I think the vascular and wound-healing implications of diabetes are the ones that could most catch people's attention and most make them want to avoid this disease. Few people probably realize that diabetes is the leading cause of limb amputations, for example.

I think this critique offers a lot which could contribute to the improvement of diabetes prevention programs.

11:29 AM  
Anonymous Anonymous said...

Thank your writing your paper about diabetes and prevention programs as that is a topic that interests me. I am a person living with Type 2 diabetes and have been concerned about diabetes prevention and disease management programs. One thing I find interesting is that I feel that most people equate diabetes as a disease older people tend to develop. And while the prevalence is high and we know that obesity and sedentary lifestyle contributes to developing diabetes, I feel that still, many see diabetes as a disease that develops in your older years and that diminishes the severity of the disease among people younger than 60. It is that assumption that I think pervades most of society.

Also, the message in diabetes prevention seems to focus on the risk factors of obesity and sedentary lifestyle which society has never regarded as positive traits (an image of fat and lazy). I fear that by focusing on these risk factors in prevention messages, we may be on the verge of creating stigma.

I also like the attention placed on the difference in diabetes prevention in minority communities. As a person living with diabetes and an Asian woman, I did not encounter many messages that were culturally competent and speaks to the context of Asian culture in prevention or diabetes management. Most food guidelines and nutritional information are from a Western perspective and does not include the Asian food that I am accustomed to and enjoy eating that will fit into my diabetes food plan. Just my two cents to offer...

This was a good critique of diabetes prevention messages and I enjoyed reading it.

Maria Pena

6:56 PM  
Anonymous Meghan McCutcheon said...

I appreciated your critique and interest in generating more effective ways to educate the public on diabetes, as my grandmother struggled with this disease and I myself feel as though I have more to learn about diabetes and what can be its devastating effects. It was also interesting to see your use of the health belief model, as we had openly critiqued this model in class, and how expansion of this model could be a more effective means of implementing an intervention.

7:50 AM  
Anonymous Anonymous said...

I enjoyed reading this thoughtful paper. I am a certified wound care specialist. I wanted to comment on the perceived severity component. I participate with a certified diabetic educator in community teaching and classes. I have two presentations - "Keep your feet" and "Wound healing from the inside and out". I do use photos of diabetic ulcers to demonstrate consequences of the disease process. While I use images to capture attention - I also provide interactive self assessment lessons with foot tracings, "shoe review", and monofilament tests for protective sensation. Patients also like the vascular doppler demonstration - actually listening to the blood flow in their extremities. It is a balancing act to present the range of outcomes - as we want them to come back to the next class! As with other health behaviors - some patients fail multiple times before finally incorporating positive behaviors into their daily lives. Again, I enjoyed this paper, and hope the clincial feedback is helpful. I intend to share this paper with my colleagues. Thank-you.

6:03 PM  
Anonymous Dr. Economides said...

Diagnosis of Diabetes can be controlled and prevented. Always consider the food you take, avoid junks and eat more fruits and vegetables. Have a regular physical activity and lastly, have a regular self testing to track the results of your effort in preventing diabetes.

7:51 PM  

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